case report surgical and orthodontic management of fused ...of a large size tooth. careful...

Case ReportSurgical and Orthodontic Management of Fused MaxillaryCentral and Lateral Incisors in Early Mixed Dentition Stage

Suresh Ramamurthy, Ramaswamy Satish, and Kalidass Priya

Department of Orthodontics, Adhiparasakthi Dental College and Hospital, Melmaruvathur, Tamilnadu 603319, India

Correspondence should be addressed to Suresh Ramamurthy; [email protected]

Received 11 July 2014; Accepted 1 October 2014; Published 13 October 2014

Academic Editor: Hamdi Cem Gungor

Copyright © 2014 Suresh Ramamurthy et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

Fusion is one of the developmental dental anomalies in which two adjacent teeth are joined at the crown level forming a single toothwith an enlarged crown. Fusion causes some clinical problems such as unaesthetic appearance, pain, caries, and malocclusion.Themanagement of fusion often needs multidisciplinary approach to give best possible esthetic and functional outcome. This paperreports a case of 9-year-old boy with fused maxillary left central and lateral incisors who was treated with 2 × 4 fixed orthodonticappliances after surgical separation of fused teeth.

1. Introduction

Tooth fusion is defined as union between two or moreseparate developing teeth [1]. The union may be betweenenamel or enamel and dentin. The terms such as synodontia,connate teeth, joined teeth, or double formations are oftenused to describe fused teeth [1]. Fusion most commonlyoccurs in the anterior region of primary dentition. It may beseen in unilateral or bilateral region [2]. Usually fusion occursbetween two normal teeth and sometimes it is seen betweennormal tooth and supernumerary tooth.

Fusion can be classified as complete and incomplete typebased upon the stage of tooth development. Complete fusiontakes place, if the contact occurs before the calcification stage,whereas incomplete takes place at the root level after theformation of crown.The prevalence of fusion in the primary,permanent, and supernumerary teeth is 0.5%, 0.1%, and 0.1%,respectively [3].

The etiology of fusion is still an enigma and manydifferent views have been put forward. Shafer et al. [4]reported that fusion resulting from pressure produced bysome physical force prolongs the contact of the developingteeth. Lowell and Soloman believe that fused teeth resultfrom some physical action that causes the young toothgerms to come into contact, thus producing necrosis of theintervening tissue, thus allowing the enamel organ and dental

papilla to fuse together [5]. Many authors have also suggestedhereditary involvement as an autosomal dominant trait withreduced penetrance [6].

This developmental anomaly may cause clinical prob-lems including esthetic impairment, pain, caries, and toothcrowding [7, 8]. Treatment of fused teeth usually requiresmultidisciplinary approaches. This case report presents thesurgical and orthodontic management of unilaterally fusedmaxillary left central and lateral incisors in the early mixeddentition stage.

2. Case Report

A 9-year-old boy referred to our clinic with complaint ofunaesthetic appearance of his upper anterior teeth. Thepatient had a nonsignificant medical history and no caseof fusion was reported in his family. Intraoral examinationrevealed localized macrodontia present in the maxillaryanterior region. Clinically maxillary left central and lateralincisorswere found to be fused and indentation running fromincisal edge to cervical margin was also observed. Maxillaryleft central and right lateral incisor crowns were distallytipped. Distolabial rotation of left lateral incisors was present.The labial and palatal aspects of both 21 and 22 teeth werefound to be caries free and healthy periodontium. Spacing

Hindawi Publishing CorporationCase Reports in DentistryVolume 2014, Article ID 109301, 4 pageshttp://dx.doi.org/10.1155/2014/109301

2 Case Reports in Dentistry

(a) (b)

(c) (d)

Figure 1: Pretreatment intraoral photos of fused maxillary left central and lateral incisors. (a) Frontal view. (b) Close-up view. (c) Left lateralview. (d) Maxillary occlusal view.

Figure 2: Pretreatment panoramic radiograph showing incompletefusion of 21 and 22 at crown level.

was present in the maxillary anterior region and distal tolateral incisor in the lower arch (Figure 1).

Orthopantogram radiograph revealed incomplete fusionof 21 and 22 at crown level with separate pulp chambers andtwo distinct roots. Radiographic evaluation also revealed aninterference in eruption of permanent canine 23 by distallytipped root of fused lateral incisor (22) (Figure 2). Treatmentwas recommended in order to improve esthetic status ofthe patient, guide the canine into normal eruption path,and intercept developing malocclusion, which may requirecomprehensive orthodontic treatment in future.

The treatment plan was explained to his family and withtheir consent; the periodontal envelope flap was raised afteranaesthetizing right side of themaxillary anterior region. Ini-tially the fused teeth were separated slightly beyond cemen-toenamel junction using long, thin diamond bur. After that,an elevator was used to separate the fused teeth; successful

separation of 21 and 22 was confirmed by clinical mobilityof individual tooth and assessed through radiograph. Theperiodontal flap was then replaced and suture placed.

After a week period, suture was removed and orthodontictreatment with 2 × 4 fixed appliance was begun in maxillaryarch. Roth 0.022 slot brackets were bonded on maxillaryincisors and preformed molar bands with buccal tube werecemented in 16 and 26. Initially, 0.014 nickel titaniumarchwire with protective sleeve was used for alignment andleveling (Figure 3), after that progressively archwires werechanged to 0.016 nickel titanium and 0.018 stainless steelwire. Maxillary anterior spaces were closed with elastomericchain in 0.018 stainless steel wire. Fused teeth were alignedat the end of six-month orthodontic treatment (Figure 4).Intraoral periapical radiograph showed improvement in rootparallelism of 21 and 22 during fixed appliance treatment(Figure 5).

3. Discussion

Developmental anomalies of teeth may occur due to abnor-malities in the differentiation of the dental lamina and thetooth germs or abnormalities in the formation of the dentalhard tissues [9]. Different terminologies have been usedto describe the anomaly of double teeth such as fusion,gemination, and twinning [10]. Isolated large teeth may bethe result of union of two adjacent tooth buds or partialsplitting of one into two. Gemination is defined as an attemptof single tooth bud to divide with the resultant formation

Case Reports in Dentistry 3

Figure 3: Intraoral view of 2 × 4 fixed appliance.

Figure 4: Midtreatment photograph shows correction of fused teeth.

Figure 5: Intraoral periapical radiograph shows root parallelism of21 and 22.

of a tooth with a bifid crown and usually a common rootand root canal. Fusion is the union of two normal teeth withseparate tooth buds leading to the formation of a joined toothwith confluence of dentin.The term twinning has sometimesbeen used to designate the production of identical structuresby division resulting in one normal and one supernumerarytooth. Various authors prefer to use the term twinning ordouble tooth to describe fusion and gemination because ofdifficulty in differentiating the two conditions [11].

Still confusion presents in differentially diagnosing fusionand gemination clinically which are two different morpho-logical dental anomalies, characterized by the formationof a large size tooth. Careful radiographical and clinicalexaminations are required to separate these two anomalies[12]. Madder’s two tooth rule may be a practical way ofdifferentiating fusion and gemination. If fused tooth arecounted as one and the number of teeth in the dental arch isless, then the term fusion is considered. However, when the

abnormal tooth is counted as one and the number of teethin dental arch is normal, then it is termed as gemination oris a case of fusion between normal and supernumerary teeth.This case revealed fusion of two teeth involving the coronalsurfaces with two separate roots and distinct pulp chambersand canals.

The clinical problems associated with fusion includeabnormal shape of the tooth leading to unaesthetic appear-ance, delayed exfoliation, occlusal disturbances, and spacediscrepancies.The presence of fissures or grooves at the unionbetween fused teeth predisposes to caries and periodontaldisease.

The treatment of fusion depends upon the patientsesthetic and functional requirements. Three ways of treat-ing incomplete fusion are as follows: crown width of thefused teeth reduced by selective grinding, surgical sectioningfollowed by restoration of teeth structures to normal size,and separation and extraction of the anomalous tooth withorthodontic closing of the space and reshaping of the teeth[13, 14]. In this case, fused teeth were successfully separatedwith long thin bur and esthetic was improved with orthodon-tic treatment.

4. Conclusion

Early identification and timely management of fused teethmay prevent orthodontic, periodontal, and endodontic com-plications. Treating fusion in young patient is easy and helpsto improve self-esteem and quality of life in future.

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper.

4 Case Reports in Dentistry

Acknowledgment

Authors would like to thank the mentor and senior personDr. Srinivasan.

References

[1] B. W. Neville, D. D. Damm, C. M. Allen, and J. E. Bouquet,“Abnormalities of teeth,” in Oral and Maxillofacial Pathology,pp. 74–75, WB Saunders, Philadelphia, Pa, USA, 2nd edition,2002.

[2] R. E. McDonald and D. R. Avery, “Fusion of teeth,” in Dentistryfor Child and Adolescent, pp. 121–122,The C. V.Mosby, St. Louis,Mo, USA, 5th edition, 1983.

[3] J. B. Taheri, M. Baharvand, and A. R. Vahidi- Ghahrodi, “Uni-lateral fusion of a mandibular third molar to a supernumerarytooth: a case report,” Journal of Dentistry of Tehran University ofMedical Sciences, vol. 2, pp. 33–35, 2005.

[4] W. G. Shafer, M. K. Hine, and B. M. Levy, A Textbook of OralPathology, WB Saunders, Philadelphia, Pa, USA, 3rd edition,1974.

[5] R. J. Lowell and A. L. Soloman, “Fused Teeth,”The Journal of theAmerican Dental Association, vol. 68, pp. 762–763, 1964.

[6] R. Stewart and G. H. Prescott, “Genetic aspects of anomaloustooth development,” inOral Facial Genetics, pp. 138–142,Mosby,St. Louis, Mo, USA, 1976.

[7] E. M. Canger, P. Celenk, and O. S. Sezgin, “Dens invaginatuson a geminated tooth: a case report,” Journal of ContemporaryDental Practice, vol. 8, no. 5, pp. 99–105, 2007.

[8] K. Gunduz and A. Acikgoz, “An unusual case of talon cusp ona geminated tooth,” Brazilian Dental Journal, vol. 17, no. 4, pp.343–346, 2006.

[9] V. Joshi, K. Pravankumar, V. Ramana, S. Joshi, and M. Saritha,“Bilateral fusion of the mandibular primary incisors: a casereport,” International Journal of Oral and Maxillofacial Pathol-ogy, vol. 2, pp. 40–43, 2011.

[10] R. Veerakumar, M. A. Pari, andM. N. Prabhu, “Caution!We areerupting as twins,” Journal of Clinical and Diagnostic Research,vol. 5, no. 5, pp. 1123–1124, 2011.

[11] A. Anantharaj, R. Sudhir, P. Praveen, K. Venkataraghavan,and P. Rani, “Fused supplemental premolars: a case report,”Streamdent, vol. 1, pp. 259–261, 2010.

[12] I. L. Turell and O. Zmener, “Endodontic therapy in a fusedmandibular molar,” Journal of Endodontics, vol. 25, no. 3, pp.208–209, 1999.

[13] M. R. Rajeswari and R. Ananthalakshmi, “Gemination: casereport and review,” Indian Journal ofMultidisciplinaryDentistry,vol. 1, pp. 355–356, 2011.

[14] M. Bhargava, D. Chaudhary, and S. Aggarwal, “Fusion present-ing as germination: a rare case report,” Journal of Oral andMaxillofacial Pathology, vol. 3, pp. 211–214, 2012.

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